OM B Control Number: 1820
- 0686 Expiration: XX/XX/XXXX

1 **Paperwork Burden Statement** According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to resp ond to this collection is required to obtain or maintain benefits ( Individuals with Disabilities Education Act (IDEA) and its corresponding regulations 34 CFR Part 304 )

. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210

- 4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 18 20

- 0686 . Note: Please do not return the completed Service Obligation Pre
- Scholarship Agreement to this address. **Service Obligation Exit Certification**  **For a Scholarship Received from a Personnel**  **Development to Improve Services and Results for**  **Children wit h Disabilities**  **Grant Awarded in Fiscal Year 2006 and Any Year Thereafter** 

Service Obligation Exit Certification

Between

_____________________________ Name of Scholar And

______________________________

Name of GranteeOM B Control Number: 1820
- 0686 Expiration: XX/XX/XXXX

2 **Upon completion or exit from gr ant**  **- supported training**  **, the grantee will require each scholar to use**  **the OMB**  **- approved**  **Exit Certification in which the scholar agrees to the terms and conditions set**  **forth in the regulations published on June 5, 2006 implementing section 662(h) of**  **IDEA (see 34**  **CFR part 304) , including the**  **requirement that the Secretary track the service obligations of scholarship recipients.**  **The regulations and Frequently Asked Questions (** **FA Qs**  **) are available at**  http://www.serviceobligations.ed.gov/ProgramRegs2006.cfm , and http://www.serviceobligations.ed.gov/2006faq.cfm

. According to section 304.23(a), the Secretary may grant a deferral or an exception to the work or repayment requirements upon request, if a scholar or an obligee can provide sufficient evidence to substantiate eligibility. The U.S. Department of Education ’s address for purposes of this Pre

- Scholarship Agreement is: OSEP PDP Data Collection Center Grants Awarded in FY2006 and Any Year Thereafter US Department of Education Office of Special Education Programs 1600 Research Blvd, RA 1297 Rockville, MD 20850OM B Control Number: 1820
- 0686 Expiration: XX/XX/XXXX

3 **Service Obligation Info rmation and Exit Certification**  **Below yo u must enter the service obligation details for the scholar/obligee. This information is**  **critical to tracking service obligation fulfillment. Note that after the completion of at least one**  **academic year of training ,**  **a scholar/obligee may begin to fulfill his or her service obligation**  **2006 Regulations: §304.30(f)(2). An academic year is defined by the program regulations as "(1) A full**  **** **time course of study -**  **(i) Taken for a period totaling at least nine months; or (ii) Taken for the equivalent of at least tw**  **o semesters, two trimesters, or three quarters; or (2) For a part -**  **time scholar, the accumulation of periods of part** **- time courses of study that is equivalent to an ‘academic**  **year’ under paragraph (a) (1) of this definition." See S**  **ec. B (1) -**  **(2); 2006 Regul ations:**  **§304.3(a)(1) -**  **(2). Scholars/obligees who exit a training program prior to completion and have not finished at least**  **one academic year of training will be referred for repayment to the Debt and P a** **yment Management Group (DPMG) of the U.S. Department**  **of Education. Scholars/Obligees will not receive credit for any employment positions held prior to the date of com**  **pletion of one academic year.**  **However, if a scholar completes a training program that is less than one academic year in**  **duration, she/he may r**  **epay through service. See 2006 Regulations: §304.30.(j)(4)(iii). All fields are required to submit the**  **record .**  **1. Program Duration:**  **Select the most appropriate option below. ○ This program is less than one academic year in duration.**  **○ This p rogram is more than one academic year in duration, but the scholar/obligee has not yet**  **completed one academic year of training. ○ This program is more than one academic year in duration and the scholar/obligee completed one**  **academic year of training on __________ (mm/dd/yyyy).**  **2. Accumulated academic years of funding under this grant (to date, if enrolled):__________**  Enter durations less than one academic year as decimals. For example, 0.5 is half of one academic year of funding. **3. Total service obl**  **igation in months under this grant (to date, if enrolled):__________** This amount is calculated by multiplying accumulated academic years of funding by 24 months. Two years of service obligation are required for every academic year of scholarship support. **4. Total funding amount under this grant (to date,**  **if enrolled):__________** Enter the amount of funding in dollars and cents.OM B Control Number: 1820
- 0686 Expiration: XX/XX/XXXX

4 **Exit Certification For a Scholarship Received from a**  **Personnel Development**  **to Improve Services and Results for Children with**  **Disabilities Grant Awarded in Fiscal Ye**  **ar 2006 and Any Year Thereafter To be completed by the Grantee Representative/Project Director when a scholar exits or completes**  **the program and certified correct by the Scholar**  **: Grant Award Number: _______________** 

**_____________________ Institution of Higher Education: ____________________________**  **Grantee Representative: ___________________________________ Project Title: _____________________________________________**  **Service Obligation Information**OM B Control Number: 1820
- 0686 Expiration: XX/XX/XXXX

5 What is the num

ber of academic years of assistance the scholar received from the Special Education

-- Personnel Development to Improve Services and Results for Children with Disabilities? What is the total amount of scholarship funding received from the Special Educati on -- Personnel Development to Improve Services and Results for Children with Disabilities program? Did the scholar complete the academic program ? What was the date of program com pletion ? If the scholar did not complete the program , did the scholar complete at least one academic year of the program? If the scholar failed to complete the academic program , or at leas t one academic year of the program , did you inform the scholar that he or she is ineligible to complete his or her service obligation through eligible employment and must repay the total amount of f unding received ? If the scholar is eligible for service obligation through eligible employment , what is the number of years of eligible employment needed to satisfy the service obligation ? I f the service obli g ation can be completed through eligible employment , what is the total number of years and months the scholar has to complete his or her service obligation (i.e., number of academic years funded times two (2) plus the five year grace peri od) ?OM B Control Number: 1820
- 0686 Expiration: XX/XX/XXXX

6 **To be completed by the Grantee Representative and**  **Scholar upon exiting or completing the program:**  **Scholar Contact Information** Scholar Name Scholar Social Security Number Scholar Address after Completing or Exiting the Program Scholar E

- ma il Addresses after Completing or Exiting the Program Scholar Telephone Number after Completing or Exiting the Program Phone number, address and e

- mail address for the scholar’s family member or friend who can forward mail, if necessary Scholar’s emp loyer, if known (Agency name, address, and telephone number)
I certify that the Service Obligation Information in this Exit Certification is correct.

____________________________________
______________ Grantee Representative Signature Date I understand , agree , and certify that the Service Obligation and Contact Information in this Exit Certification are correct.

________________________ ______________________ ______________ Scholar Name Scholar Signature Date (Please print) **Note: The completed Exit Certification**  **must be**  **certified within 30 days of completion or exit from**  **the program by both the grantee and the scholar in**  **the Service Obligation database at**  **http://serviceobligation.ed.gov.**